Research
Public health workers lack guidance on dilemmas

If avian flu breaks out, how do public health officials decide who gets the antiviral medication? Should a clinic dentist extract an uninsured patient's tooth if it's salvageable but too expensive to repair?

Public health workers who face ethical dilemmas in their everyday work without a systemized plan or framework for decision-making must make gut-wrenching decisions that often mean deciding between the haves and have-nots, says Nancy Baum, a doctoral candidate at the School of Public Health.

Tailored decision-making guides that are tested on real-life situations may have great benefit in helping public health practitioners grapple with perplexing issues, research indicates.

"We know a lot about ethical challenges in medicine, but not as much in the realm of public health," Baum says. "But ethical challenges are not just limited to individual doctor-patient relationships. They also exist at the community health and population health level."

Baum and colleagues Peter Jacobson of SPH, Susan Goold of the Medical School and Sara Gollust of the University of Pennsylvania identified five broad categories of ethical issues practitioners face: determining appropriate use of public health authority, resource allocation, political interference, ensuring standards of quality of care and questioning the role of public health.

Yet, public health workers don't receive much, if any, formalized training in this area. Nor do they have a systemized oath for guidance similar to what physicians have.

The researchers interviewed 45 public health workers in various occupations in 13 Michigan health departments to determine the ethical challenges workers face and how they solve those problems.

They found that practitioners invoked a wide range of values in addition to those typically associated with public health, such as social justice, to respond to ethical challenges. They did not often use frameworks for decision-making, but rather conferred with colleagues or depended on their own moral upbringing.

The field of public health ethics is relatively new. In 2002 the Public Health Leadership Society developed a code of ethics, but it's unclear how that's being applied or whether most practitioners even know it exists, Baum says.

"Doctors and patients have been guided by research and writing about bioethics for 30 to 40 years. Entire organizations exist to study bioethics," she says. "There might be some real benefit to developing frameworks to structure some of these decision-making processes in public health."